Mental Health Inpatient Services Quality Management System

A comprehensive QMS template designed for psychiatric hospitals, inpatient behavioral health units, and acute psychiatric care facilities.

🏥 Designed For

• Psychiatric Hospitals - Freestanding behavioral health facilities
• Hospital Psychiatric Units - Inpatient psych units within general hospitals
• Crisis Stabilization Units - Short-term acute psychiatric care
• Child/Adolescent Psychiatric Units - Pediatric behavioral health
• Geriatric Psychiatric Units - Older adult mental health care
• Forensic Psychiatric Facilities - Court-ordered treatment settings
• Residential Treatment Centers - Extended care facilities

📋 Regulatory Framework

This template supports compliance with:

• The Joint Commission - Behavioral Health Care accreditation
• CMS Conditions of Participation - Psychiatric hospital requirements
• State Mental Health Authority - State licensing regulations
• 42 CFR Part 482 - Hospital Conditions of Participation
• HIPAA - Patient privacy requirements
• EMTALA - Emergency psychiatric presentations
• State Commitment Laws - Involuntary treatment regulations
• APA Practice Guidelines - Psychiatric treatment standards
• NPSG - National Patient Safety Goals (behavioral health)
• Nurse Practice Act - Psychiatric nursing regulations

Repository Structure

├── SOPs/
│   ├── Admission-Discharge/   # Voluntary/involuntary admission, discharge planning
│   ├── Assessment/            # Psychiatric evaluation, risk assessment, treatment planning
│   ├── Safety/                # Suicide prevention, elopement, environmental safety
│   ├── Restraint-Seclusion/   # Use, monitoring, debriefing, documentation
│   ├── Medication/            # Psychotropic meds, PRN protocols, monitoring
│   └── General/               # Document control, training, CAPA
├── Forms/
│   ├── Admission-Forms/       # Consent, legal status, voluntary/involuntary
│   ├── Assessment-Tools/      # PHQ-9, GAD-7, Columbia, mental status
│   ├── Safety-Plans/          # Suicide safety plans, precaution levels
│   ├── Restraint-Records/     # Restraint/seclusion orders, monitoring logs
│   ├── Treatment-Plans/       # Individualized treatment plans, goals
│   └── Training/              # Competency assessments
├── Policies/                  # Institutional policies
├── Work-Instructions/         # Step-by-step procedures
└── Templates/                 # Document templates

Document Numbering Convention

• POL-XXX: Policies
• SOP-ADM-XXX: Admission/Discharge SOPs
• SOP-ASM-XXX: Assessment SOPs
• SOP-SAF-XXX: Safety SOPs
• SOP-RS-XXX: Restraint/Seclusion SOPs
• SOP-MED-XXX: Medication SOPs
• WI-XXX: Work Instructions
• FRM-XXX: Forms and Records

🤖 AI-Powered Assistance

This repository includes AtomicAI, your mental health QMS assistant. Mention @atomicai in any issue or pull request to:

• Draft admission and assessment procedures
• Create suicide risk assessment protocols
• Generate restraint/seclusion procedures
• Develop medication management SOPs
• Create safety and elopement prevention plans
• Review documents for Joint Commission compliance

Example Prompts

• "@atomicai create an SOP for suicide risk assessment using Columbia-Suicide Severity Rating Scale"
• "@atomicai draft an involuntary admission procedure per state requirements"
• "@atomicai write a restraint/seclusion policy meeting CMS requirements"
• "@atomicai create a psychiatric medication monitoring protocol"
• "@atomicai develop an elopement prevention and response procedure"
• "@atomicai create a therapeutic milieu safety checklist"

Getting Started

1. Align with State Laws - Review involuntary commitment and patient rights laws
2. Establish Safety Protocols - Implement suicide prevention and environmental safety
3. Define Assessment Standards - Standardize psychiatric evaluation tools
4. Set Up Medication Monitoring - Configure psychotropic medication protocols
5. Train Staff - Crisis intervention and de-escalation training

Key Documents to Create First

1. Suicide Risk Assessment SOP - Standardized screening and intervention
2. Involuntary Admission Procedure - Legal holds and commitment process
3. Restraint and Seclusion Policy - CMS-compliant R/S procedures
4. Environmental Safety Checklist - Ligature risk and contraband
5. Elopement Prevention SOP - Risk assessment and precautions
6. Treatment Planning SOP - Individualized treatment plan development
7. Discharge Planning Procedure - Safe transitions and aftercare

Special Considerations for Psychiatric Inpatient Care

Patient Safety

• Suicide risk screening and assessment
• Environmental safety (ligature points, sharps)
• Contraband prevention and searches
• Elopement risk and prevention
• Patient supervision levels

Legal and Rights

• Voluntary vs. involuntary status
• Informed consent for treatment
• Patient rights notification
• Grievance procedures
• Advance directives and healthcare proxies

Restraint and Seclusion

• Least restrictive interventions
• Physician orders and time limits
• Continuous monitoring requirements
• Debriefing and documentation
• Reduction initiatives

Treatment

• Psychiatric evaluation and diagnosis
• Treatment plan development
• Medication management and monitoring
• Group and individual therapy
• Discharge planning and aftercare

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This template is maintained by AtomicQMS. For questions, open an issue in this repository.